Pressure Ulcers and Medical Nutrition

TherapyBy: Meghan Coffey

Agenda1. Objectives

2. Introduction

• Ice Breaker

• Overview of pressure ulcers

• Prevalence

• Cost

• Mortality

3. Research

• Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.

• Effect of an arginine-containing nutritional supplement on a pressure ulcer healing in community spinal patients.

• The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers.

4. Common Themes and Conclusions

5. Summary

Objectives

By the end of the presentation, the audience will:

1. List one factor that increases risk of developing a pressure ulcer.

2. Identify one nutrition intervention that can benefit pressure ulcer healing rates.

3. Share experiences regarding nutrition interventions and pressure ulcer healing.

Ice BreakerPlease tell us your name and a nutrition intervention that you consider when dealing with pressure ulcers .

Pressure Ulcers • Skin breakdown that occurs

over a boney prominence caused by pressure or friction.

• Risk Factors:o Obesityo Elderlyo Bed Riddeno Chronic Disease,

Infection, Injurieso Incontinence o Paralyzed o Poor nutritional status

Stages of Pressure Ulcers

Normal Skin Stage 1

Stages of Pressure Ulcers

Stage 2 Stage 3

Stages of Pressure Ulcers

Stage 4 Unstagable

Prevalence

Prevalence of pressure ulcers in the US is widespread in all settingswith estimates of: 10% to 18% in acute care 2.3% to 28% in long-term care,

and 0% to 29% in home care

Cost

• The Centers for Medicare/Medicaid Services (CMS) reports the cost of treating a pressure ulcer in acute care (as a secondary diagnosis) is as much as $43,180.00 per hospital stay.

• Contributing cost factors include:o increased length of stay;o infection;o high tech support surfaces; ando decreased functional ability.

Mortality

There were 503,300 pressure ulcer-related hospitalizations in 2006.

• 45,500 listed pressure ulcers as the primary diagnosis.

• Of these admissions, one in 25 admissions ended in death.

• 457,800 noted pressure ulcer as the secondary diagnosis.

• Of these admissions, the death rate was one in eight.

How can nutrition play a role in pressure ulcer healing?

Three studies were evaluated taking a closer look at how different nutritional approaches and supplements can effect pressure ulcer healing in a range of demographic groups.

General population

Elderly (65+)

Spinal Cord Injury Patients

Study 1:Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.Emanuele Cereda, Anna Gini, Carlo Pedrolli, Alfredo Vanotti Journal of American Geriatric Society, 2009

The purpose of this study was to investigate whether a disease-specific nutritional approach is more beneficial than a standard dietary approach to the healing of pressure ulcers in institutionalized elderly patients.

Number of participants that completed the study: 28

Study 1: Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.

Study Design All participants received 30kcal/kg

Treatment group- Participants who were fed orally, received two bottles

(400mL) of a high-energy enriched formula. Along with a standard hospital diet to reach the estimated energy requirements.

Tube fed participants received 1,000mL of a high-protein enriched supplement with arginine, zinc, and vitamin C infused together with appropriate volumes of an isocaloric standard formula to reach the energy requirements. 

Study 1: Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.

Study Design All participants received 30kcal/kg

Control group- Participants who were orally fed, the nutritional

treatment consisted of a standard hospital diet (16% energy from protein) without any additional supplement.

In subjects who were tube fed, energy and the infusion of appropriate volumes of a standard formula satisfied protein requirements.

Results Disease-specific nutritional

treatment was associated with a significantly higher rate of pressure ulcer healing.

When comparing healing rate, the treatment group was statistically different from control group by week 12.

P<.02 (Mann-Whitney U test)

Study 1: Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.

Results Percentage of decrease in

pressure ulcer area was significantly different in treatment group from control at Weeks 8 and 12.

P<.02 and P<.005, respectively (Mann-Whitney U test)

Study 1: Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.

Discussion

The data shows that pressure ulcer healing was improved significantly in the intervention group.

However, all of the participant’s dietary intake (kcal and protein) increased as a result of participating in the study.

What are your thoughts?

Study 1: Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.

Study 2: Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients S. Brewer, K. Desneves, L. Pearce, K. Mills, L. Dunn, D. Brown, T. Crowe Journal of Wound Care, 2010  

The purpose of this study was to determine whether or not the use of an arginine-containing nutritional supplement could result in significantly shorter pressure ulcer healing times in people with spinal cord injuries living in the community, compared with a comparative historical control group.

Population: 18 participants in the intervention group 17 participant in the historical control

group

Study 2: Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients

Study Design

Intervention group-

Participants were asked to consume the equivalent of two packets of a commercially available arginine-containing powder (Arginaid, Nestlé Nutrition, Minneapolis, MN, US) each day until their wounds were fully healed. 

Control group-

Historical controls were used for expected healing time of pressure ulcers.

• Reported by Bennett et al. who reviewed 12 different studies to generate estimates of the average time-to-healing for different stages of pressure ulcers without nutritional supplementation.

• The time-to-healing rates of patients in the intervention group were compared with these expected rates.

Study 2: Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients

Results Patients receiving the arginine

containing supplement demonstrated statistically and clinically faster healing rates for all pressure ulcer categories compared with the expected time-to-healing reported by the historical control.

P<.006

Study 2: Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients

Discussion The supplement was not arginine

alone, it contained additional CHO, Vitamin C and E. Therefore, the results are more based on an arginine mixture.

The study only included well-nourished healthy people.

No dietary control or food record

Study 3: The effect of different doses of an arginine-containing supplement on the healing of pressure ulcersLeigh B, Desneves K, Rafferty J, Pearce L, King S, Woodward MC, Brown D, Martin R, Crowe TCJournal of Wound Care 2012

This study was to investigate whether a dose of 4.5g of arginine in the form of a commercial oral nutritional supplement can show equal benefit in the healing rate of pressure ulcers compared with the existing evidence for 9g of arginine.

Population:

23 participants

Study 3: The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers

Study Design

Patients were randomly assigned to one of two treatment groups for the 3-week study period.

Treatment groups- The 4.5g arginine group consumed and standard hospital

diet (one packet of Arginaid, Nestle Medical Nutrition). The 9.0g arginine group consumed and standard hospital

diet plus 9g arginine (two packets of Arginaid)

Pseudo Control group- Consisted of a prior 3-week study from the same hospital that

had showed clinically and statistically significant changes in pressure ulcer healing without an arginine supplement.

Study 3: The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers.

Data collection The size and severity of the pressure ulcers were

measured at baseline and at each week of the 3-week study period by an independently contract RN and the PUSH tool was used to assess pressure ulcers. 

A 3-day food and fluid record, based on the bedside charts, was completed by the nursing staff for all patients at the start of the study and at the end of week 3 or on complete healing.

Study 3: The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers.

Data collection Body weight of the patients was recorded at

baseline and every week during the 3-week study period.

Nutritional status was assessed at baseline using the subjective global assessment (SGA). Patients were evaluated and rated with the SGA as being: Well-nourished, Mildly/moderately malnourished, or Severely malnourished.  

Study 3: The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers.

Results There was no apparent

difference in healing rates between the two doses investigated and, therefore, according to this study, a dose of 4.5g of arginine per day could provide a similar benefit in healing to 9.0g of arginine.

P<.991

Common Themes and Conclusions

Limited Evidence

o Existing studies have small sample sizes and often require further research with larger RCT studies to validate findings.

Screening and Assessments

o Early identification of under nutrition and the correction of nutritional deficits promote wound healing.

o When there is no presence of a pressure ulcer the goal is prevention.

Well-nourished vs. Malnourished

o In all studies, rates of pressure ulcer healing was faster in well-nourished patients.

o Patients who are malnourished are more likely to develop pressure ulcers and heal more slowly.

Nutrition: A Critical Component of Wound Healing.

Function of nutrients and wound healing

o Carbohydrate inadequate CHO intake can lead to muscle wasting loss of subcutaneous tissue and poor wound healing.

o Fat fat carries fat soluble vitamins and provides insulation under the skin and padding to bony prominences.

o Protein promoting positive nitrogen balance has been link to improved healing rates. Studies on the effectiveness of consuming supplements containing arginine and glutamine to treat pressure ulcers are inconclusive.

o Water patients with draining wounds need additional fluids to replace lost fluid. Studies show improving hydration status may increase tissue oxygenation.

Nutrition: A Critical Component of Wound Healing.

Function of nutrients and wound healing

1. Vitamin C- enhances activation of leukocytes and macrophages in the wound bed and is essential for collagen synthesis. Deficiency in vitamin C can prolong healing time. No clinical evidence that mega doses improve wound healing.

2. B vitamins (coenzymes)- their effects have not been demonstrated in pressure ulcers.

3. Vitamin A- responsible for epithelium maintenance and stimulates collagen formation. Vitamin A deficiency is rare but may result in delayed wound healing and increased susceptibility to infection.

4. Vitamin E- antioxidant responsible for fat metabolism and collagen synthesis. Does not appear to play active role in wound healing but deficiency will impede the absorption of Vitamin A.

Nutrition: A Critical Component of Wound Healing.Function of nutrients and wound healing

1. Iron-component of hemoglobin. Low iron could effect wound healing due to decrease oxygen to carried to wound bed.

2. Zinc- cofactor for collagen formation, also metabolizes protein and liberates vitamin A from the liver. Wounds with increased drainage may trigger a zinc deficiency. No clinical evidence supporting supplementation.

Summary:

o Caloric, protein and fluid requirements should be individualized to least restrictive diet appropriate.

1. 30-35kcal/kg

2. 1.25-1.5g protein/kg

o Fortified and enhanced foods can help provide additional kcal and protein.

o Provide nutritional supplements to reverse under nutrition and promote pressure ulcer healing (Boost, Magic Cup, Multivitamin).

o Avoid therapeutic diets or restrictions that will result in unappealing meals and limited intake.

o Monitor for dehydration

o Offer vitamin and mineral supplements when dietary intake is poor.

Post Test

MC- 65 Year old female with history of DM2 status post knee replacement. Lives alone, recent weight loss of 10 lbs. Reports recently has had limited intake due to difficulty getting around and standing for long periods of time to prepare meals. List risk factors that increase

development of developing a pressure ulcer.

Post Test

Identify one nutrition intervention that could benefit MC and reduce her risk of developing a pressure ulcer.

References Wound Care Nurse

National Pressure Ulcer Advisory Panel

http://www.npuap.org/

Academy of Nutrition and Dietetics Evidence Based Research Library

The Centers for Medicare/Medicaid Services (CMS)

Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.Emanuele Cereda, Anna Gini, Carlo Pedrolli, Alfredo Vanotti Journal of American Geriatric Society, 2009

Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients S. Brewer, K. Desneves, L. Pearce, K. Mills, L. Dunn, D. Brown, T. Crowe Journal of Wound Care, 2010

The effect of different doses of an arginine-containing supplement on the healing of pressure ulcersLeigh B, Desneves K, Rafferty J, Pearce L, King S, Woodward MC, Brown D, Martin R, Crowe TCJournal of Wound Care 2012

Questions?

Thank You!

Meghan Coffey

Sodexo Distance Dietetic Intern

meghanrcoffey@gmail.com